A Pulmonary Pathway for ACLS: An Idea Whose Time Has
Come. Is it time for a change to the ACLS certification
process? One expert says yes.
As a committed lifelong learner, I was surprised at the
sense of resentment I experienced recently while preparing for
certification in advanced cardiac life support (ACLS). Like
thousands of respiratory therapists across the country, I had
dutifully constructed flash cards for reviewing no less than
20 different cardiac rhythms, a dozen or more
pharmaceuticals—including their bolus and infusion rates—and a
collection of abbreviated algorithms for treating a variety of
cardiac arrhythmias and arrest scenarios.
The American Heart Association’s Web site states: “The ACLS
Provider Course provides the knowledge and skills needed to
evaluate and manage the first 10 minutes of an adult
ventricular fibrillation/ventricular tachycardia (VF/VT)
arrest. Providers are expected to learn to manage 10 core ACLS
cases: a respiratory emergency, four types of cardiac arrest
(simple VF/VT, complex VF/VT, PEA and asystole), four types of
pre-arrest emergencies (bradycardia, stable tachycardia,
unstable tachycardia and acute coronary syndromes), and
stroke.”
Why should I have a problem with that? Indeed, a
substantial portion of the ACLS course work provides important
essential knowledge and skills that every respiratory
therapist should demonstrate proficiency in performing. The
resentment set in when I considered the number of brain cells
that were being squandered on identification and treatment of
relatively esoteric cardiac arrhythmias, against the
relatively superfluous attention to essential respiratory
skills. While respiratory therapists busy themselves
memorizing (and soon forgetting) the subtleties of P-wave
anomalies and S-T interval measurements, I might ask who is
being trained and tested on the knowledge and skills
respiratory therapists actually need and use? The answer is no
one.
The 500-page ACLS manual is divided into 18 chapters, with
only one covering the entire field of airways, oxygenation,
and ventilation. Many RTs skip that chapter entirely, because
the actual test questions and clinical skills they are
required to demonstrate are so basic. But that does not mean
we have nothing to learn in those areas. While laryngeal mask
airways (LMAs), esophageal-tracheal ventilation tubes,
intubation, emergency cricothyroidotomy, cephalic
mouth-to-mask, and other ventilation techniques are discussed,
they are inadequately tested. Algorithms include calling for
an arterial blood gas, but the knowledge and skills needed to
actually draw the blood and interpret ABGs are no longer
tested. ABG and arterial blood gas do not even appear as
entries in the index. Meanwhile, an entire chapter is devoted
to vascular access and establishing and maintaining central
and peripheral lines.
Respiratory therapists preparing for ACLS often feel like
square pegs trying to squeeze into round holes as they
memorize information they simply never use. This can easily be
verified by conducting a roundtable discussion with any group
of competent ACLS-certified respiratory therapists a few
months after they have completed the course. Ask them about
torsades de pointes, and most will quickly and correctly
declare that it is not a city in Italy. One bright individual
might define it as a unique subtype of polymorphic ventricular
tachycardia, but many will be hard pressed to define it and
suggest a plan of treatment, much less recite the 44 drugs
known to prolong Q-T interval or induce torsades. The PJs,
PATs, PSVTs, and so many other arrhythmias quickly become lost
in what the ACLS manual admits is a nomenclature potpourri.
The old adage “use it or lose it” takes its toll over time as
RTs continually hone and nurture the skills and techniques
they employ daily, while losing the skills they are not called
upon to use. There are critically important skill sets RTs use
every day and others they employ occasionally, which are
de-emphasized in the current ACLS program. RTs need to
demonstrate competency in the skills they need every day,
while being challenged to review the skills they use less
frequently. This critical need was recently substantiated by
an observational study of in-hospital cardiac arrests that
found CPR quality was inconsistent and that ventilation rates
were high, even when performed by well-trained hospital
staff.1
I am not proposing that we throw out the proverbial baby
with the bathwater. ACLS certification is a valuable tool, and
like physicians and nurses, respiratory therapists need to
have regular reviews of their knowledge and skills.
Could there be a better way for respiratory therapists to
get the most out of ACLS? It would not be hard to envision an
ACLS program that at some point offered participants a choice.
They could choose a cardiac pathway, a pulmonary pathway, or
both. The cardiac pathway would present ACLS unchanged from
its present format. The pulmonary pathway would include much
of the ACLS core material and recognition of life-threatening
arrhythmias, but would then focus much more intensely on
advanced-level respiratory skills in place of the cardiac
algorithms. These would include:
• A much more rigorous ventilation scenario. Currently,
ACLS offers participants a quick demonstration of the bag and
mask technique. Participants then apply the technique, often
in an awkward, haphazard manner. Effective bag/mask
ventilation looks a lot easier than it is. The ACLS manual
describes it as “easy to learn, a lifetime to master.” Too
true. Anyone who has observed an anesthesiologist perform the
technique can quickly tell the difference between the
experienced practitioner and a neophyte. Instructors are
usually effective at observing errors and identifying
ineffective efforts, then sending the individual on to the
next station. A pulmonary pathway would require participants
to demonstrate absolute competence in this and other essential
skills, while challenging them to troubleshoot a variety of
scenarios and correct unexpected problems. Patients vomit,
they lose their dentures, and oxygen lines become
disconnected. Intubations can be performed both orally and via
a nasal passage—what are the pros and cons of each? Although
the ACLS course consistently acknowledges that establishing
and maintaining an airway is essential, the skills required to
make that happen are sometimes glossed over as participants
scurry to the next station to focus on IV therapy and cardiac
arrhythmias. While some team members scrutinize the cardiac
rhythm and plot a plan of action, someone else needs to be
completely competent (beyond what ACLS currently requires) in
establishing, maintaining, and methodically reassessing the
airway, breathing, and ventilation components.
• Arterial blood gas draws, handling, and interpretation.
ACLS algorithms currently require the candidate to call for a
blood gas at an appropriate time, but the skills required to
obtain and interpret the ABG have been curtailed over the
years. A pulmonary pathway would require participants to
demonstrate proper ABG technique, including an understanding
of the pros and cons of alternate sites including brachial,
femoral, and pedal areas. Candidates would be required to
demonstrate competent technique, identify an array of possible
complications, and be tested on correct ABG handling and
transport requirements.
Interpretation of ABG results is another critically
important skill that should be tested. Is that an arterial or
a mixed venous sample? Is the patient being substantially
hyperventilated? What might the repercussions of that be? The
ability to correctly evaluate an ABG and suggest changes in
the plan of treatment based on those results is at least as
important as identifying a second-degree type I heart block
and treating it accordingly.
• Respiratory emergency scenarios and algorithms. ACLS
testing scenarios and algorithms favor cardiac crisis, often
at the expense of respiratory complications that challenge
clinicians every day. Assessment of impending respiratory
failure and subsequent cardiac arrest, including status
asthmaticus, pulmonary embolus, COPD exacerbations, carbon
monoxide poisoning, patient transport via portable
ventilators, noninvasive ventilation, and the many possible
ensuing challenges and complications, are all ripe for
exploration. What are the mechanisms and implications of
hyperventilation-induced hypotension during CPR?2
Inquiring minds should want to know. In an apparent effort to
make ACLS a kinder, gentler experience, many of the essential
skills that respiratory therapists bring to the bedside have
been given short shrift in favor of nursing skills.
ACLS offers a systematic, evidence-based approach that
provides physicians, nurses, and respiratory therapists with
an exceptional tool for training and certification in the
management of patients in VF/VT arrest. The trainers are
required to meet a high level of competency and the materials
are constantly revised and updated. It is time for a revision
that addresses the real-life needs of respiratory
therapists.
I am not proposing a dumbing down of our profession, but
rather the development of a system that better matches our
needs. While one team member scrutinizes the important
distinction between a ventricular tachycardia and
supraventricular tachycardia with aberrancy, another team
member needs to be focusing on other critically important
rescue needs. An optional pulmonary pathway for ACLS would be
a benefit to both our patients and our profession.
John A. Wolfe, RRT, CPFT, is a clinical specialist,
Northern Colorado Medical Center, Greeley, Colo, and a member
of RT’s editorial board.
References
1. Abella BS, Alvarado JP,
Myklebust H, et al. Quality of cardiopulmonary resuscitation
during in-hospital cardiac arrest. JAMA.
2005;293(3):305–10.
2. Aufderheide TP, Sigurdsson G,
Pirrallo RG, et al. Hyperventilation-induced hypotension
during cardiopulmonary resuscitation. Circulation.
2004;109(16):1960–5.